NEW PATIENT INFORMATION DATE: / / HOME PHONE: NAME: (First) (MI) (Last) ADDRESS: CITY: STATE: ZIP CODE: BIRTHDATE: / / Sex: Male Female Marital Status: S M D W Occupation: Work Phone: Employer: City & State: Social Security: E-Mail Address: Cell Phone: PATIENT INFORMATION: Spouse Name: Occupation: Work Phone: Employer: City & State: Social Security: Date of Birth: SPOUSE INFORMATION: How did you find out about us? TV (Channel?) Website Internet Facebook Trib OTHER Referral from a physician Referral from a friend/family (Name) (Name) Have you had Physical Therapy this year? (Circle one) YES NO If yes, where Have you been or are you on Home Health Care? (Circle one) YES NO Is this related to a Workman s Comp Case or Auto Accident Case? (Circle one) YES NO If YES, please provide Workman s Comp/Auto Accident information to Front Desk. Please note: We do not accept third party payments. It is the patient s responsibility to pay for therapy charges. Primary Care Physician: (If other than the referring physician) Address: City: State: Zip Code: Specialty: Telephone: Pharmacy: Phone: Insurance Information: Primary: Group or ID#: Insured s Name: Secondary: Group or ID#: Insured s Name: In Case of Emergency, Contact: Phone: Assignment of Benefits/Release of Information: I authorize payment of insurance benefits directly to Illinois Back Institute. I authorize to execute any documents necessary to secure the payment of benefits and obtain any records from any other source necessary for the course of my treatment. I agree to be financially responsible for all charges incurred during treatment by Illinois Back Institute including my insurance deductible co-payment, and services not covered by my insurance carrier or paid in full through any settlement or court case. Any remaining balances I will pay in full per the policies of Countryview Medical Center dba Illinois Back Institute. Signature: Date: MRI No Yes Disc Films Cleared for Vibration: No Yes
NAME: AGE: DATE: WHAT IS YOUR REASON FOR YOUR VISIT TODAY? Primary Care Physician: DATE OF LAST PHYSICAL EXAM: HEALTH STATUS (please circle): For Women Date of Last Menstrual Period: Last Pap Smear: Date of Last Mammogram: Pregnant Yes / No No. of Children Complications, (if any) with childbirth? Have you experienced (please circle): Abnormal Pap Smear Abnormal Bleeding Breast Lump/Pain Vaginal Discharge HEALTH HISTORY (please circle): Patient History Chills Poor Appetite Chest Pain Itching Depression Bloating High/Low Blood Pressure Changes In Moles Dizziness/Fainting Bowel Changes Swelling in Ankles Rash Fever Constipation Varicose Veins Scars Sweats Diarrhea Blurred/Double Vision Sore (non- healing) Forgetfulness Excessive Hunger/Thirst Earache/Ringing In Ears Low Back Pain Headaches/Migraines Gas Sinus Problems Neck Pain Sleep Loss Indigestion Allergies Leg/Arm Pain Weight Loss Nausea/Vomiting Nosebleeds Other: Nervousness Difficulty Swallowing Persistent Cough Numbness Rectal Bleeding Bruise Easily AIDS Chicken Pox Hernia Polio Tonsilitis Alcoholism Diabetes High Cholesterol Prostate Problems Typhoid Fever Anemia Emphysema Kidney/Liver Disease Psychiatric Care Ulcers Appendicitis Epilepsy Measles Rheumatic Fever Vaginal Infections Bronchitis Gout Miscarriage Scarlet Fever Venereal Disease Cancer Heart Disease Pacemaker Stroke Other: Cataracts Hepatitis Pneumonia Thyroid Problems
Name: Date: / / Please List Prescriptions and OTC Medications: (Use back if needed) Please List Medical Allergies: Family Health History Relation Age Status of Health Age of Death Cause of Death Father Mother Brother (s) Sister (s) Family History (please check below if any applies) Check Condition Relationship Arthritis, Gout Asthma, Hay Fever Cancer Chemical Dependency Diabetes Heart Disease, Strokes High Blood Pressure Kidney Disease Tuberculosis Other Health Habits (please mark if using the following) Caffeine: How much? Tobacco: How much? Drugs: Water: Surgeries and Hospitalizations Date Reason for Hospitalization/Type of Surgery Outcome/Results How much? How much? Other: I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. / / Patient Signature Date / / Reviewed By Date
Name: Date: / / Please state your initial problem and/or reason for visiting today? Date Condition/Problem began? What is the frequency of your symptoms? Constant Frequent Intermittent Occasional SCALE of 0 to 10; 0 representing no pain and 10 the most severe pain, please circle the appropriate number below. Please rate your pain today? 1 2 3 4 5 6 7 8 9 10 Since your pain started, how would you rate your least pain level? 1 2 3 4 5 6 7 8 9 10 Since your pain started, how would you rate your worst pain level? 1 2 3 4 5 6 7 8 9 10 If your initial pain is a pain complaint, does it radiate? YES No If yes, where to? Please check if your initial complaint effects your movement by the following: Inflexibility Stiffness Spasm Cramp If your initial complaint gives you sensations, please check from the following: Crawling Pins & Needles Burning Stinging Tingling Stabbing Shooting Excruciating Deadness Hurting Throbbing Dull Prickly Pulsating Aching Pounding What aggravates your complaint? Flashing Lights Looking Up/Down Looking side to side Driving Pushing Carrying Getting in/out of Car What relieves you initial complaint? Resting Sitting Tylenol Sneezing Lifting Coughing Sitting Anger Standing Stress Walking Emotional Upset Pulling Straining at BM Climbing Stairs Other Sleeping Shower Pain Pills Cold Advil Treatment Heat Aspirin Mineral Ice Exercising Stooping Depression Getting out of Bed Repetitive Movements Walking up hill Other
Patient Name: Date: / / Please Circle the correct answer for each question: 1. Have you ever had blood clots? Yes No 2. Have you ever had a hernia? Yes No a. If yes, How long ago? 3. Do you have Spondylolisthesis? Yes No 4. Have you ever had a compression fracture? Yes No 5. Have you ever had a hip, knee or foot implant (artificial)? Yes No 6. Are you pregnant? Yes No 7. Do you have a pacemaker? Yes No 8. Do you have any metal in your body (Plates or screws)? Yes No 9. Do you have an infection? Yes No 10. Do you have diabetes? Yes No 11. Do you have any stents for your Heart or Arteries? Yes No 12. Do you have a severe heart problem? Yes No 13. Do you have epilepsy? Yes No 14. Do you or have you had cancer? Yes No
NOTICE OF PRIVACY PRACTICES In compliance with a newly enacted Federal Law, the Health Insurance Portability and Accountability Act (HIPAA), The Illinois Back Institute is informing you of your privacy rights. Please review this notice carefully. What is HIPAA? HIPAA is a law passed by Congress in 1996 to improve the efficiency and effectiveness of the healthcare system. It requires health care professionals to adhere to privacy and security standards in order to protect their patient s Personal Health Information (PHI). PHI is confidential information about a patient, including demographic information. What are my rights under HIPAA? Under HIPAA you have a right to request the following as long as a request is made in writing to the attention of the Privacy Officer and applicable fees are paid. There is a possibility that your request may be denied. If your request is denied we will explain why it was denied in writing. You have a right to inspect and obtain a copy of your PHI. We will respond to your request within 30 days. In most cases your request will be honored and a copy of your PHI will be mailed to you. You have a right to request an amendment of PHI. If you feel that your PHI is inaccurate or incomplete, you may request an amendment to your PHI. We will respond to your request within 60 days. If we honor your request we will amend your PHI and notify you and applicable parties. We will deny your request if we determine your PHI to be correct or complete, if your request was not created by us, or if PHI is not available for inspection. You have the right to know what disclosure(s) of your PHI have been made. You have a right to request a listing of who your PHI was sent to, when it was sent, what content of your PHI was sent and for what purpose. We will respond to your request within 60 days. There will be no charge to you for an initial request. Additionally, your request may not include disclosures made for national security reasons, to law enforcement officials/correctional facilities, or disclosures made prior to June 1, 2004 Updated: October 14, 2009. You have a right to request confidential communications of PHI. We will honor all reasonable requests to keep communications confidential. A reasonable request is one that specifies an alternative address, gives other means of contact and provides detailed information on how payment will be handled. You have a right to request restrictions on the use and disclosure of PHI, however we are not required to agree to your request. Your request must state specific restrictions requested and to whom the restrictions would apply. You have a right to receive a hard copy of this notice. This notice can also be accessed on our website www.illinoisbackpain.com. How will The Illinois Back Institute Use and Disclose PHI under HIPAA? HIPAA allows us to use and disclose your PHI for the purposes of Treatment, Payment and Healthcare Operations. We will specifically use and disclose your PHI to communicate with your physician and to, upon request, assist your insurance company with the processing of your claims. Additionally, we will use your basic demographic information to notify you of new services or facilities. Your authorization is not required for Use and Disclosure of PHI for the purposes of Treatment, Payment and Healthcare Operations. Listed are other instances in which Use and Disclosure of your PHI is allowed without your authorization. Disclosure to those Involved in the Individual s Care when necessary, we will make a professional decision to disclose PHI to family members, close friends or other persons involved in and assisting in your care when you approve or when are not able or present to approve. Uses and Disclosures Required by Law as required by law we are required to use and disclose PHI for the following reasons: Use and Disclose PHI for Public Health Activities Examples include: communicable diseases, sexually transmitted diseases, lead poisoning, Reyes Syndrome, etc., to public health officials. Disclose PHI about Victims of Abuse, Neglect, or Domestic Violence - Examples include: child abuse and neglect; an abused or neglected nursing home resident; a patient over 60 years old involved in elder abuse. Uses and Disclosure of Health Oversight Activities we may use and release PHI to be used for audits, investigations, licensure issues, etc.
Disclosure for Judicial and Administrative Proceedings we may disclose limited PHI to the appropriate authorities as a result of a court order subpoena, discovery request, etc. Disclosure for Law Enforcement Purposes we may disclose reasonably necessary PHI to law enforcement officials to identify or locate a suspect, fugitive, material witness or missing person. Uses and Disclosures Related to Decedents we may use and disclose PHI to a coroner or medical examiner and funeral directors as required by law. Uses and Disclosures Related to Cadaveric Organ, Eye or Tissue Donations we may use and release PHI in order to facilitate organ, eye or tissue donations. Uses and Disclosures to Avert a Serious Threat to Health or Safety we may use and release PHI to public health and other authorities required by law in order to prevent a serious threat to your health or safety. Uses and Disclosures for Specialized Government Functions we may use and release PHI for military/veterans activities and national security/intelligence activities. Use and Disclosure of PHI in Emergency Situations - in the event of an eminent threat to the safety of a patient, we may disclose PHI to prevent or lessen the threat. Uses and Disclosures of PHI for Marketing Purposes - The Illinois Back Institute will notify you of new services and facilities unless you specify otherwise. Unless you authorize such a disclosure we will not disclose your PHI for marketing purposes. Uses and Disclosures of PHI for Research Purposes we do not use or disclose identifiable PHI for research purposes, unless you authorize such use and disclosure. Uses and Disclosures requiring the Patients Authorization - we must obtain your written authorization if we are interested in using and or disclosing your PHI for reasons other than treatment, payment and health care operations. You may revoke your authorization at any time. What does HIPAA require of The Illinois Back Institute? The Illinois Back Institute must maintain the privacy of PHI, abide by the terms of this notice and provide patients with a revised notice, if necessary. Where can I file a privacy complaint? If you feel your privacy rights have been violated, contact The Illinois Back Institute s Privacy Officer, or contact the regional Department of Health and Human Services at 312-886- 2359 or www.hhs.gov. Receipt of Notice of Privacy Practices Form Effective June 1, 2004 Updated: October 14, 2009 I,, hereby acknowledge receipt of The Illinois Back Institute s Notice of Privacy Practices. The Illinois Back Institute will use or disclose my PHI for the purposes of carrying out treatment, payment and health care operations. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential information. I understand The Illinois Back Institute has reserved a right to change its privacy practices that are described in the Notice. I also understand a copy of any Revised Notice will be provided to me or made available at my next office visit. I give my consent for The Illinois Back Institute to notify me of new facilities or services. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to The Illinois Back Institute. Signed: Date: If you are not the patient, please specify your relationship to the patient.
Oswestry Pain Questionnaire THE NECK DISABILITY INDEX QUESTIONNAIRE PATIENT NAME: DATE: How long have you had neck pain? years months weeks On the diagram below, please indicate where you are experiencing pain or other symptoms, right now. Please complete both sides of this form. A = ACHE P = PINS & NEEDLES B = BURNING N = NUMBNESS S = STABBING O = OTHER